- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $133.47 / $133.47 / $133.47
| Facility | 26 | $133.47 | $133.47 | $133.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.12 / $133.47 / $645.37
| Professional | 26 | $109.12 | $133.47 | $645.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $129.46 / $158.69 / $202.61
| Professional | 26 | $129.46 | $158.69 | $202.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $454.31 / $454.31 / $454.31
| Facility | 26 | $454.31 | $454.31 | $454.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $159.13 / $226.41 / $255.12
| Professional | 26 | $159.13 | $226.41 | $255.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $99.39 / $116.93 / $194.40
| Professional | 26 | $99.39 | $116.93 | $194.40 |